Authors:

Richard Gonzalo, MD,  Asher Lippe, DO, Lindsey Peterson, MD, Raquel Cancho-Otero, MD, Anna Serur, MD, FACS, FACRS, Jingjing Sherman, MD, FACS, FASMBS. Englewood health medical center.

Objective:

To report a rare case of transverse colon obstruction secondary to split omentum herniated above Petersen’s closure after a gastric bypass, that caused right colon dilation and pneumatosis.

Methods and Procedures:

This patient was a 44 year old male with a history of chronic pain, obesity, GERD who had previously undergone a laparoscopic gastric sleeve. He had severe reflux symptoms and was found to have a hiatal hernia and esophagitis on workup. He underwent an uncomplicated laparoscopic conversion of sleeve to bypass and hiatal hernia repair. Intraoperatively the omentum was very heavy and was split to accommodate the Roux limb. Petersen’s defect was closed with running ethibond.

On POD 2 he had developed worsening right lower quadrant abdominal pain and localized peritonitis. A CT abdomen/pelvis with PO/IV contrast was performed which revealed a dilated transverse and right colon with evidence of pneumatosis in the right colon/cecum and portal venous gas. 

The patient went to the operating room emergently for robotic assisted diagnostic laparoscopy. The cecum was found to be well perfused and viable but had a 10 cm tear along the tinea. The serosal tear was repaired with a running vicryl suture. The left leaflet of the omentum was seen herniating above Petersen’s closure, posterior to the Roux limb, causing proximal dilation and associated CT findings. The herniated omentum was reduced and a partial omentectomy was performed.

Results:

The patient was found to have tomographic evidence of colon compromise. Intraoperatively he was found to have a leaflet of omentum that herniated above Peterson’s space that kinked the colon causing a mechanical obstruction, the increased intraluminal pressure back on the cecum allowed for development of a serosal tear. The serosal tear was primarily repaired and the culprit omentum was resected. The patient recovered well postoperatively and was discharged home on routine bariatric diet and having bowel function.

Conclusion:

Colonic obstruction and pneumatosis is a rare but serious complication following laparoscopic conversion of gastric sleeve to bypass. Early recognition followed by timely surgical intervention is critical in preventing further bowel compromise and improving patient outcomes. This case underscores the importance of thoroughly working up a patient with atypical postoperative complaints after bariatric surgery.